It's not what it looks like: atypical rash in cryoglobulinaemic vasculitis

Abstract

A 48-year-old man with a history of intravenous drug use and chronic, untreated hepatitis C presented to the emergency room with acute bilateral lower extremity swelling, erythema and maculopapular rash. Serum C4 levels were low, but dermatology felt the rash was due to venous stasis dermatitis. The patient was discharged with compression stockings, but returned to the hospital 5 days later with no improvement in his symptoms. A more extensive laboratory workup revealed hepatitis C viral load of 4 million, elevated serum cryoglobulins, and skin biopsy showing leucocytoclastic vasculitis. He was treated with oral prednisone, with complete resolution of his symptoms after 2 weeks. He was scheduled for follow-up in gastroenterology clinic for treatment of his hepatitis C for definitive cure of his mixed cryoglobulinaemia, but failed to get insurance authorisation to begin treatment with Harvoni. He presented to the hospital 4 months later with diffuse alveolar haemorrhage.

It Is Just a Rash They Said! Acute Skin Manifestation in a Patient With Vasculitis in Rural Hospitals

“…First-line treatment for CryoVas involves immunosuppression with high-dose corticosteroids such as intravenous methylprednisolone followed by oral tapering for severe cases, mild-to-moderate presentations can be treated with oral prednisone. 6 , 7 For steroid sparing and resistant vasculitis, cyclophosphamide, and/or plasmapheresis are thought to be effective treatment options. In our patient, once his cutaneous vasculitis was diagnosed, he was started on high-dose methylprednisolone with significant improvement in his symptoms.…”

Chronic hepatitis C-related cryoglobulinaemic vasculitis manifesting as non-healing skin ulcers: a case presentation

“…Cryoglobulinaemia (CG) is a condition where cryoglobulins (immunoglobulins) precipitate in the tissues at temperatures below 37°C, reversibly dissolving on rewarming [1][2][3][4][5][6] . Precipitation usually occurs in the lower extremities, with vasculitide deposition in the small to medium blood vessels resulting in cutaneous ischaemia and skin lesions or ulcers.…”

“…CG is characterised by a myriad of clinical manifestations including purpura, asthenia, arthralgia and variable organ involvement -kidney, nervous system, gastrointestinal system, interstitial lung involvement and endocrine disorders (diabetes) 7 . Diagnosis may include laboratory findings, histopathology and clinical presentation 6 .…”